In July this year myself and two fellow second year midwifery students embarked on an elective second year midwifery placement to West Pokot, North West Kenya. We were fortunate to accompany registered midwife and founder of the charity Beyond FGM, Cath Holland.

Beyond FGM is a grass roots charity working with the inspirational group Kepsteno Rotwa (meaning ‘Abandon the knife’) which works tirelessly to eradicate FGM (female genital mutilation) in the localised area of West Pokot. Many of the communities in which the charity operates, are highly impoverished, isolated, marginalised and often unaware of the tragic consequences of performing FGM or that the practice is now illegal. Girls who suffer FGM are sold into childhood marriage for dowries, they become property with no human rights and a lifetime of struggle, abuse and are deprived of education. Sensitisation to FGM for these communities is therefore a vital activity. Abandonment of FGM and facilitating girls to attend school, are key elements to ensuring girls are able to make their own choices and live in freedom.

During our elective we were able to observe and participate in the activities of the FGM group. We travelled to a remote tribal community (Takywa) two hours from where we were staying in Ortum. We were driven through rivers and bush to get there. We went on market day to ensure we had maximum numbers to undertake FGM sensitisation talks with the local community. Whilst there we witnessed girls present who should have been at school. Instead they donned beads in their hair, a symbol that they had undergone or were about to undergo FGM. There was such poverty in this community. They welcomed us, and were attentive to what we/the group had to say. The community were keen to reform their FGM practice and with the group’s help could promote the benefits of getting their girls into education.

Meeting the community for FGM sensitisation talks in Takywa)

We also met and spent time with the girls who have been rescued by the FGM group and who are now in education in Ortum Girls Boarding School, West Pokot. Some of the girls had escaped from FGM had run from their homes and their families, others had been cut but had run to escape becoming child brides, others had been defiled. It was heartbreaking to hear their stories.

The charity is raising funds for a refuge dormitory to accommodate the girls over school holidays to avoid the need to for them to return home and face the risk of FGM. It is possible to donate a brick towards the build here.

We also had the opportunity to observe practices and facilities in the local Ortum Mission Hospital. The hospital is primarily run by students, resources and facilities are very poor and therefore, perinatal and maternal mortality is not uncommon and is often expected. During one of the deliveries a baby required resuscitation. There was little equipment available, the baby was being solely cared for by students and many midwifery and resuscitation skills were lacking, no one seemed to fully know what to do. Myself and another student assisted in the resuscitation due to asphyxia. Fortunately the baby survived and was discharged a few days later with his mother who had lost her first child to asphyxia which the mother told me but sadly none of the staff caring for her was aware of her history. The way we cared for the baby was observed by the students, it was an opportunity whereby they learnt from us and visa versa. I was able to ask numerous questions which prompted personal reflection on practice and facilitated discussion and reflection about the care of the baby.

Labour Ward Ortum Mission Hospital

In the larger government hospital in Kapenguria, the conditions were also poor, crowded and unsanitary despite which women were travelling great distances to this hospital as treatment was supposedly free (this was not the case in reality). In both Kapenguria and Ortum hospitals the labour wards were very small consisting of two delivery beds which women were located to when in the second stage of labour, prior to which they would share a communal and relatively public bay. Women are deprived of privacy and dignity and are expected to deliver alongside one another. There was no room for birthing partners due to size of the rooms and the sheer volume of staff and students who crammed into them. Consent is a virtually a non-existent concept, however myself and my fellow students ensured we consistently gained consent and were respectful to the women and families we had contact with. Although this may have seemed a foreign concept in the environment we were in, I would hope this added value to the care we provided and facilitated an opportunity for the staff and students we worked with to witness a different way of practicing.

Homebirth is common whereby women are attended to by traditional birth attendants (TBAs) who perform routine episiotomy or ‘home episiotomy’ (bilateral episiotomy) in the presence of FGM. This is carried out with unsterilized items and no pain relief. The risk of bleeding following the practice is high and can be fatal for women who are unable to access medical care in a timely way due to living considerable distances away or cannot afford treatment which they are charged for. We witnessed a case such as this and were able to talk to the woman about her experience after the event once she was well enough, thankfully she and her baby were well when they were discharged.

In Kenya, students are trained in nursing, community health and midwifery inclusively. I was able to spend some time with staff and students assisting in the vaccination of babies. They received many of our routine vaccinations with the addition of Hep B, yellow fever and anti-diarrhoea immunisations on clinic day. Clinic day also included antenatal clinic. Women are offered a maximum of four antenatal appointments, many women do not attend any and are cared for solely by tradition birth attendants in their communities who have no formal maternity training. Scans in pregnancy are not routine, gestation based on last menstrual cycle is not usually known, the girls and women themselves may not even know their own exact age. Using the number of moons since missed menstrual cycle is commonly used to estimate due date in communities by TBAs. In clinic gestation is therefore frequently determined from palpation and height of the fundus which can be problematic if a baby is simply small or large for gestation. This was a good opportunity to use basic midwifery skills in palpation, there was no scan to confirm breech of which there were several diagnosed, no sonicade to auscultate fetal heart only pinards. All women were offered HIV tests, this is the one time I witnessed informed consent practiced. Alcoholism appeared to be a real problem amongst the women however there is nowhere to refer them to unlike the support and services we offer in the UK. A large proportion of women in the Pokot community have undergone FGM, it is rare for them not to have been cut. Despite traditional birth attendants often the circumcisers being away of the complications, fatality, morbidity and risks during childbirth, the practice continues regardless and women therefore who have undergone FGM and are approaching childbirth are described has ‘having one foot in the grave’. Therefore although there has been lots of success in eradicating FGM, there is still much work to be done, by addressing the issue worldwide, we can truly prevent the practice in the UK also.

My time in Kenya was eye opening and this report only briefly touches on some of our experiences. It was challenging living and working with such basic resources, however, the fact that we had electricity and access to water most of the time, four walls and a roof to live in was far more than most had, the poverty was crippling. It was a struggle to witness the impersonal nature of maternity care, the lack of dignity, respect and informed consent as well as the brutal abusive practice of FGM. However, glimmers of hope were seen in the success of the group on FGM, the strength of the women and girls, the generosity of the communities despite having so little and seeing girls in school growing into confident women. I feel privileged to have had the opportunity to share knowledge and gain knowledge. We were welcomed into the community which enabled our immersion into the culture, language and behaviours and this facilitated acquisition of invaluable insight into maternity practices. This experience has had a positive impact on underpinning my midwifery practice as well as my knowledge around FGM which is especially pertinent at a time when FGM in the UK is a growing concern. I include a recent ITV news report here regarding FGM. The news report in fact shows an alternative right of passage ceremony which the FGM group introduced and which has been very successful in the Pokot community as a celebration and safe alternative to FGM.

I also want to take this opportunity to thank the Eleanor Peel Trust for the funding towards this life changing experience, I am forever grateful.